Risk factors for perioperative death and stroke after carotid endarterectomy: results of the new york carotid artery surgery study.
OBJECTIVE
The benefit of carotid endarterectomy is heavily influenced by the risk of perioperative death or stroke. This study developed a multivariable model predicting the risk of death or stroke within 30 days of carotid endarterectomy.


METHODS
The New York Carotid Artery Surgery (NYCAS) Study is a population-based cohort of 9308 carotid endarterectomies performed on Medicare patients from January 1998 through June 1999 in New York State. Detailed clinical data were abstracted from medical charts to assess sociodemographic, neurological, and comorbidity risk factors. Deaths and strokes within 30 days of surgery were confirmed by physician overreading. Multivariable logistic regression was used to identify independent patient risk factors.


RESULTS
The 30-day rate of death or stroke was 2.71% among asymptomatic patients with no history of stroke/transient ischemic attack (TIA), 4.06% among asymptomatic ones with a distant history of stroke/TIA, 5.62% among those operated on for carotid TIA, 7.89% of those with stroke, and 13.33% in those with crescendo TIA/stroke-in-evolution. Significant multivariable predictors of death or stroke included: age >/=80 years (OR, 1.30; 95% CI, 1.03 to 1.64), nonwhite (OR, 1.83; 1.23 to 2.72), admission from the emergency department (OR, 1.95; 1.50 to 2.54), asymptomatic but distant history of stroke/TIA (OR, 1.40; 1.02 to 1.94), TIA as an indication for surgery (OR, 1.81; 1.39 to 2.36), stroke as the indication (OR, 2.40; 1.74 to 3.31), crescendo TIA/stroke-in-evolution (OR, 3.61; 1.15 to 11.28), contralateral carotid stenosis >/=50% (OR, 1.44; 1.15 to 1.79), severe disability (OR, 2.94; 1.91 to 4.50), coronary artery disease (OR, 1.51; 1.20 to 1.91), and diabetes on insulin (OR, 1.55; 1.10 to 2.18). Presence of a deep carotid ulcer was of borderline significance (OR, 2.08; 0.93 to 4.68).


CONCLUSIONS
Several sociodemographic, neurological, and comorbidity risk factors predicted perioperative death or stroke after carotid endarterectomy. This information may help inform decisions about appropriate patient selection, assessments about the impact of different surgical processes of care on outcomes, and facilitate comparisons of risk-adjusted outcomes among providers.
Halm
Ethan A
EA
Department of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8889, USA. Ethan.Halm@UTsouthwestern.edu
Tuhrim
Stanley
S
Wang
Jason J
JJ
Rockman
Caron
C
Riles
Thomas S
TS
Chassin
Mark R
MR
D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D002340:Carotid Artery Diseases / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D015897:Comorbidity; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality*; D016021:Epidemiologic Studies; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009518:New York / Q000453:epidemiology; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality*; D044469:Racial Groups; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D020521:Stroke / Q000401:mortality*